Procedure



Procedure | |Date: | |Time: | | |

|Name of Contrast: | |Date of injection: | |Time of injection: | |

|Site Involved |Left: |Hand |Forearm |Antecubital |Other: ______________________ |

| |Right: |Hand |Forearm |Antecubital |Other: ______________________ |

Discharge Instructions for Infiltration of IV Contrast

|Elevate affected extremity above the heart for next 24 hours |

|Apply ice pack to site for 20 to 30 minutes 3 to 5 times a day for 1 or 2 days |

|You may take over the counter pain medication as needed for discomfort |

|Notify the Imaging Department or your physician if you notice any of the following at the infiltration site or the affected extremity: |

|redness |blistering | |

|swelling |change in color | |

|Go to the Emergency Department if you experience any of the following: |

|Skin around the needle site becomes dark and peels |

|Affected arm or leg becomes red |

|Affected arm or leg has red streaks |

|Purulent drainage at the needle site |

|Temperature (fever) of 101( Fahrenheit or higher |

|If you go to the Emergency Department, please inform the physician and/or the nurse that you had an infiltration of IV Contrast , date and where administered. |

If you have any questions or problems develop after you arrive home please call Imaging Services Department

|Laurel Regional Hospital Imaging Services |(301) 497-7994 |

|Prince Georges Hospital Center Imaging Services: |(301) 618-3341 |

I have read and understand the above instructions. I have received a copy of these instructions.

|Patient Signature | |Date | |Time | |

|Technologist | |Date | |Time | |

|Radiologist/ Referring Physician | |Date | |Time | |

|DISCHARGE INSTRUCTIONS FOR INFILTRATION OF IV CONTRAST |PATIENT LABEL |

|DIMENSIONS HEALTHCARE SYSTEM | |

| | |

| | |

|7-595 (8/11) | |

White – Medical Record Yellow – Patient Copy

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